Continental Airlines Crash

[Canus Chinookus]

My uninformed dash 8 pilot guess is that they were fast coming in (like most turboprops in a jet world "keep the speed up") then pulled the power back to idle at the last possible minute, they then dropped the gear and flaps as they slowed to the appropriate speeds then were distracted and forgot to bring the power up. The 6 bladed props in addition to the gear and flap would decelerate them very quickly causing them to stall if not caught.

This situation to me is likely because the wx wasn't bad and nobody flies the Dash on the sim profile of 140kts while trying to operate in most ATC environments (especially in the U.S.) unless the wx is the shits

Just my opinion

Now add 'significant' airframe icing to the mix, and now you need a PILE of power to accelerate, or recover from a conventional stall. We pilots get used to certain power settings for certain phases of flight. I remember on the 737-200 we had tons of target power settings for everything. Probably same for the Q. Maybe never thought of the icing, set the power where it usually was for configuring flap/gear, and got distracted... I've been distracted by a high workload in the sim enough times to know how easy it is to miss something. Dammit! Aviate, Navigate, Communicate!!!

[ModerateChop]

Pilot Action May Have Led to Crash

Flight Data Show Response to Loss of Speed Resulted in Deadly Stall That Downed Plane

By J. LYNN LUNSFORD and ANDY PASZTOR

Investigators examining last week's Continental Connection plane crash have gathered evidence that pilot commands -- not a buildup of ice on the wings and tail -- likely initiated the fatal dive of the twin-engine Bombardier Q400 into a neighborhood six miles short of the Buffalo, N.Y., airport, according to people familiar with the situation.

The commuter plane slowed to an unsafe speed as it approached the airport, causing an automatic stall warning, these people said. The pilot pulled back sharply on the plane's controls and added power instead of following the proper procedure of pushing forward to lower the plane's nose to regain speed, they said. He held the controls there, locking the airplane into a deadly stall, they added.

The crash on Feb. 12 at about 10:20 p.m. EST killed all 49 aboard and one person on the ground.The investigation is still at an early stage, and National Transportation Safety Board officials have warned about ruling out potential causes or prematurely jumping to conclusions. But in the past few days, government and industry crash experts have gained a better understanding of the sequence of events as they have compared information from the plane's flight recorders with radar and weather data.

Mark Rosenker, the NTSB's acting chairman, said Tuesday that investigators still have "lots of data that needs to be examined," and "still more evidence that needs to be collected," before announcing firm conclusions.

The Q400 was operated by Colgan Air Inc., an unit of Pinnacle Airlines Inc., which was operating the flight on behalf of Continental Airlines Inc. Joe Williams, a spokesman for Pinnacle, declined to comment about details of the accident while the safety board was investigating. A spokeswoman for the Air Line Pilots Association, which represents the pilots, declined to comment.

Investigators initially focused their attention on potential ice buildup on the plane's wings -- a perpetual hazard of aviation. People familiar with the investigation cautioned that they still aren't sure whether icing may have played a contributing role in the crash because it was on the minds of the pilots, but they noted that another Q400 flew through "moderate" icing conditions on the same route from Newark, N.J., to Buffalo the same night, landing without incident less than an hour after the crash.

A Bombardier spokesman said Tuesday that the company is "not aware of any serious icing incident on this aircraft" since it was introduced into service in February 2000.

According to people familiar with the investigation, Capt. Marvin Renslow, 47 years old, who lived outside Tampa, Fla., was at the controls of Flight 3407. The safety board said Mr. Renslow was relatively new to the Q400, which he began flying only in December, when he upgraded from another type of airplane. First Officer Rebecca Lynne Shaw, 24, of Seattle, had accumulated 774 hours in the 74-seat aircraft.

The recovered flight data described in detail how the crew of Continental Flight 3407 handled the emergency, the people said.

During the flight from Newark, Mr. Renslow and Ms. Shaw noticed ice building up on the windshield and wings of the airplane after they had already activated the craft's de-icing system, which inflates a series of rubber bladders on the leading edge of the wings and tail surfaces to break up accumulated ice.

According to the plane's flight recorders, Flight 3407's descent into Buffalo was routine until roughly a minute before impact, when the crew lowered the landing gear, followed by the command to extend the wing flaps, which enable the plane to fly at slower speeds.

Almost immediately, these people say, the plane's air speed slowed rapidly, causing a stall-warning device known as a "stick-shaker" to cause the pilots' control column to vibrate. This was followed by a "stick-pusher," which automatically forces the stick forward.

At this point, the captain appears to have pulled back with enough force to overpower the stick-pusher and shoved the throttles to full power, according to people familiar with the matter. Safety board officials said the nose pitched up to a 31-degree angle. Already at a dangerously low speed, the wings immediately stopped generating lift. The plane whipped to the left and then entered a steep right turn, losing 800 feet of altitude in less than five seconds. At one point the right wing was perpendicular to the ground, according to information taken from the flight data recorder.

The pilots continued to fight with the controls almost all the way to the ground, and in the final moments, "it appeared that they were beginning to make headway when they ran out of altitude," said one person who looked at the data.

A crash with many similarities occurred five years ago involving a regional jet operated by Pinnacle. Following that crash, which killed the two pilots outside Jefferson City, Mo., the safety board urged Pinnacle and other commuter operations to revamp training procedures, including how to recover from certain types of stalls. Investigators are seeking more information from Pinnacle about how it changed its procedures in the wake of the previous crash, as well as specific details about the training provided for the pilots on Flight 3407.

Pinnacle's Mr. Williams said that following the previous crash, "we continually evaluated our procedures in accordance with our commitment to safety."

—Paulo Prada contributed to this article.

http://online.wsj.com/article/SB1234929058...d=djemalertNEWS

[Canus Chinookus]

Aviate

Navigate

Communicate.

Fly the Eff'n airplane!!!

[Don Hudson]

There is information about the ILS23 at BUF causing a possible pitch-up if the gs is captured before the loc.

Now, the way I understand autoflight systems is, the gs can't be captured before the loc and I can't see that varying over aircraft type.

CC;

Aviate

Navigate

Communicate.

Fly the Eff'n airplane!!!

Well, we're both aviators and we both know how easy that is to say and that sometimes it inexplicably doesn't happen for whatever reason - take a look above. I'm sure we both know good, highly skilled very dedicated people to whom very bad things have happened. We know that aviation is like that.

I think the following is worth reading:

For those who doubt it could happen

It is far too early to seriously consider cause.

However, the above information even if true, I think the discussion and perhaps the investigation may subtlely shift from icing and the airplane towards experience, training including aerodynamics, safety programs and human factors including cockpit dynamics.

[RGT]

Kind of an interesting graphic Representation

http://www.nytimes.com/interactive/2009/02...falo-Crash.html

[Moon The Loon]

Now, the way I understand autoflight systems is, the gs can't be captured before the loc and I can't see that varying over aircraft type.

Actually, the B757 and 767 could and would do that. It can make the little hairs on the back of your neck stand up pretty straight if your SA is not 100%.

[Guest woxof]

Now, the way I understand autoflight systems is, the gs can't be captured before the loc and I can't see that varying over aircraft type.

I believe a flight director with Manual Glideslope mode will capture the glideslope before localizer capture although I haven't tried it yet.

[conehead]

I believe a flight director with Manual Glideslope mode will capture the glideslope before localizer capture...

That may be so, but a Flight Director will not cause any input to Control Surfaces. A Flight Director is "indication only", for the Pilot.... however, if coupled to a Autopilot, that's another story...

[Guest woxof]

That may be so, but a Flight Director will not cause any input to Control Surfaces. A Flight Director is "indication only", for the Pilot.... however, if coupled to a Autopilot, that's another story...

Many planes have manual glideslope capability on the flight director and the autopilot.

[RFL]

Now, the way I understand autoflight systems is, the gs can't be captured before the loc and I can't see that varying over aircraft type.

I believe that is true for the Airbus types but not many others.

[Canus Chinookus]

I can confirm the NG's won't lock on the G/S either until the Loc does.

[Pivot]

That would be your NG's. Not all of the NG's do that.

[blues deville]

That would be your NG's. Not all of the NG's do that.

Correct. These are all customer options, such as full time or part time flight directors.

[Canus Chinookus]

interesting!

[Don Hudson]

Though the LOC was captured first, there is a good lesson here regarding false G/S's:

Air New Zealand B767-300 approach to Faleolo; False Glideslope near accident

[Moon The Loon]

"Shortly after landing flap selection the PF (Pilot Flying) noted an anomaly in DME versus altitude. Around the same time the PNF (Pilot Not Flying), while trying to establish visual contact with the airfield and runway, became aware that visual cues did not correspond with what was expected. The SP (Supplementary Pilot) also became aware of an anomaly in aircraft position at approximately the same time as the two other crew members."

FABULOUS S/A:

This says it all - use the automatics but don't let them take you to hell. Work it out in your head first and use that as your LAR decision to accept/reject what the automatics are doing to your machine. If it doesn't LAR, then STOP what you're doing, get out of there, figure it out before trying it again.

20 years ago, a Montreal Centre controller asked me how I was navigating to FRANX. I told him "LAR Navigation, sir." He accepted that explanation for about 5 seconds before asking me to define LAR:

"Looks About Right, sir," after which I was given vectors. (He didn't like it that I was gonna miss FRANX by 1/2 mile).

[RGT]

203 pages, thats a lot of reading

..."go-around go-around"

http://www.youtube.com/watch?v=0qaDVaKQSkQ

[Guest woxof]

FABULOUS S/A:

Actually, they were criticized by the Operational Factors Division of the NTSB for a lack of S/A.

"1. False glideslope indications are a fairly frequent occurrence. Pilot training and

procedures require cross-checking and monitoring distance/altitude progress to

preclude following a false glideslope indication.

2. The incident approach was an ILS DME approach, which required the use of DME as an integral part of the approach procedure. Page 115 states that “The approach cannot be legally flown if the marker beacons/DME are inoperative; therefore the

information provided by those facilities must be displayed.” The flight crew did not

utilize the DME information in conducting the approach.

3. There was an intent to intercept the glideslope at 2,500 feet, but no apparent mention of 7.5 DME as the appropriate intercept distance, nor were there periodic

distance/altitude checks as conveniently depicted on the profile view of the approach

plate.

4. There did not appear to be adequate crew coordinate between the PF, PNF, and the SP. No one appeared to be monitoring the flight progress, but rather appeared too focused on energy management and looking out the window for the airport. Normal crewcoordination during an instrument approach requires crosschecking all appropriate navigational aids and indications. The SP made an attempt to reconcile

altitude/distance, but disregarded them as erroneous.

5. The crew disregarded an “uneasy” and “surprised” sense that the glideslope had

captured early, but did not confirm the altitude with the DME. Page 118 states: “The

PF cross-checked the DME and verbalized to the other crew that the information did

not make sense.” Yet he continued the approach. “The SP computed the DME/altitude

equation and recognized the answer did not compare to the aircraft’s actual altitude”

yet he did not challenge the PF or the PNF.

6. Page 146. I disagree with the statement, “Whilst it is acknowledged the crew had anopportunity to detect the erroneous glideslope prior to making the go-around decision,it is the view of the investigation that a high proportion of line crews would have madethe same decision at glideslope capture.” I believe that that only a very limitednumber of line crews would have disregarded DME vs. ALT at glideslope capture.

7. This incident approach appears to demonstrate a lack of proper preparation,

inappropriate approach procedures, and a breakdown of crew coordination and crew

resource management

8. Finding 3.1.5 If the aircraft was managed in accordance with company SOPs, there

should be recommendations relevant to preparation and performance of ILS DME

approaches."

In other words, they got down to about 400 feet AGL before going around when the 2500 feet was the crossing altitude of the FAF(or its equivalent). Fortunately New Zealand did an in-depth investigation and discovered other instances of similar scenarios.

The Air New Zealand report is quite large. For a faster overview of the whole issue I have posted this link.

http://www.flightsafety.org/fsd/fsd_jul02.pdf

Air France had a similar occurrence in Rio and after investigating more in depth found other occurrences as well as can be read in the above publication.

http://www.smartcockpit.com/pdf/flightops/aircraft/12

Be suspicious if the loc and GS are centered when they shouldn't be or if for some strange reason you are doing the perfect ILS approach.

[Moon The Loon]

Actually, they were criticized by the Operational Factors Division of the NTSB for a lack of S/A.

Won't disagree with you there but if that one glimmer of S/A that they did experience prevented The Big One, at least they are alive to learn the other lessens, eh?

[Guest woxof]

Very true, but what clued them in finally was stated on page 21 about the Captain (He made a comment at this time, reported as 's*** those lights are close'). That is when they started going around. Fortunately the weather was not too bad that night.

Just shows the importance of checking your crossing altitudes carefully. Unforunately it frequently occurs at a very busy time in the cockpit.

[Don Hudson]

I think the significant improvement among many in electronic displays (vice mechanical) is the ability to display the map of where the airplane is, but an equally important display which has not widely been adopted or modified into 320-737NG fleet types for example (it's standard in the 380 & likely the 787 and seems available for corporate/private aircraft), is the vertical profile display. Similar to the planned/charted vertical profile in the Jepps, it shows the actual vertical situation of the aircraft above a data-base driven terrain model plus the relationship with the runway. It shows trend information and can even display TCAS information.The technology has been around for over a decade:

380 Display:

[conehead]

Don; the first time I saw this type of display was on the Embraer 170/190's. And I thought; this is a thing of beauty. That vertical flight profile on the PFD must be sooo useful!

[mo32a]

Southwest just sent this to their pilots yesterday in regard to the approach in Buffalo. Interesting!

"There is a potentially significant hazard concerning the ILS to runway 23 in BUF.

Information has been received indicating it is possible to obtain a significant nose pitch up, in some cases as much as 30 degrees, if the glide slope is allowed to capture before established on centerline. Pilots who are preparing to configure and land have the potential to experience abrupt pitch up, slow airspeed, and approach to stall if conditions present themselves in a certain manner.

This effect is the result of an earthen obstruction close enough to the ILS to affect the integrity of the glide slope signal. This has resulted in the issuance of an advisory given on ATIS which states that "the ILS Glide Slope for runway 23 is unusable beyond 5 degrees right of course." When attempting to intercept the runway 23 ILS from right traffic, the ILS glide slope indication may read full deflection down. Just prior to intercept it may then move up in such as manner as to enable approach mode to capture in such a way as to result in a nose up pitch and loss of airspeed. Southwest Airlines has issued a notice reading: "Until further notice, when executing the KBUF ILS/LOC Runway 23, DO NOT select Approach Mode until established on the localizer inbound."

[Moon The Loon]

That advisory has been around for a little while. I think (like the autopilot "reports"), it is a red herring in this sad occurrence.

[J.O.]

Ice only one factor in flight 3407 forensics